P - 48326Building
Inspections
763-572-3604
763-502-4977 FAX
DATE .. � � �� � r
SITE ADDRESS yC
THIS APPLICANT IS:
PLUMBING
RESIDENTIAL APPLICATION
CITY OF FRIDLEY
EFFECTIVE 1-1-2012
��� YOUR E-MAIL�AiDDRESS
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❑ O R �pNTRACTOR
PROPERTY NAME:
OWNER/ ADD�ss:
TENANT
CONTRACTOR NAME:�
SUBMIT A COPY OF
YOUR STATE STATE LICENSE #_
LICENSE, BOND AND STATE BOND #_
CERTIFICATE OF ADDRESS:��
INSURANCE
PHONE ��rC °
PERMIT TYPE I� SINGLE FAMILY
TYPE OF WORK: �� NEw
CITY_
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❑ TWO FAMILY
,,'�REPLACEMENT
❑ TOWNHOUSE
Permit No.: � b�Z-� ��.�
Received By:—�_
Date �� L! ��oi�� � ! �
,�
_ EXP DATE
_ EXP DATE
(✓: `��°� A
TATE ZIP.
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DETAILED DESCRIPTION OF WORK ��' ��a � /P � //'�'r 5' -��:�' ��� .�' � 6'^� � ✓` ` f - `�
� ��<:� � �''c�>_ 4 0��• ivfc � ��
FEES ARE BASED ON $]0.00 PER FIXTURE, EXCEPT WHERE NOTED. FIXTURES: (INDICATE TOTAL NUMBER OF EACH BELOW). MINIMUM FEE
$ 5.50.
� BATH SINK/LAV FLOOR DRAINS 1 SHOWER WATER PIPING
' BATHTUB GAS PIPING (NEED CITY LIC) SWIMMING POOL WATER SOFTNER ($35)
CLOTHES WASHER KITCHEN SINK s�WATER CLOSET BACKFLOW PREV. ($15)
DISHWASHER LAUNDRY TRAY WATER HEATER ($35) FOR IRRIGATION
WATER METER OTHER
Number nf fixtures � $1 t1.04 . �,� � $ I Q.(?0' — $ � '
�lumber of �xtures (a> �l 5.00 x � I 5.0(7 — $
tilumber of fixtures '�u�, $35.4(} X $35.OQ? _ $
State Surcharge $ 5.00 '
��. . �� . � ���� �
(1R'iIN�'�ZtTiVI �40 fl0) `Tata1= $ �J�
THIS IS AN APPLICATION FOR A PERMIT-NOT VALID LTNTIL PROCESSED
I hereby apply for a plumbing permit and I acknowledge that the information above is complete and accurate; that the work will be in
conformance with the ordinances and codes of the City of Fridley and with the Minnesota Construction Codes; that I understand this is
not a permit but only a�} applicati� r it and work is not to start without a permit on site; that the work will be in accordance
with the approved plan i�,the c'' all rk whi ires review and appr�o 1 of plan . � �/ �
SIGNANRE OF APPLICANT ' � a"? � �*��tN� PR1NT NA�/!L9/lc°'?9' G�Lii✓'-l_ /l�Pi+ DATE� L�'���l�//�•
APPROVALINSPECTORS.SIGl'iIATIfR� .,� �� ____� � �� DATE
City of Fridley
Building Inspections Department
6431 University Avenue NE, Fridley, MN 55432
763-572-3604
FAX: 763-502-4977